DASH scores show distal radius fracture treatment no better in 10-year period

Issue: October 2013

The introduction of rule-based standardized treatment and new surgical methods have given the orthopaedic community hope to improve the results after distal radius fracture both at short-term with return to normal and long-term with fewer patients having complaints after a year. With the use of a standardized patient outcome instrument — DASH — the patient’s opinion of the result can be recorded and with the follow-up taking place entirely via mail, large cohorts can be followed. But, the DASH instrument seems to be too blunt to be able to show a difference, if there is any, according to Swedish researchers.

“We have previously made a randomized study comparing open vs. closed surgery with the open group being superior — not only after 3 months as many other [studies have shown], but also after 12 months,” PhD student Marcus Landgren, MD, and Magnus Tägil, MD, PhD, of the department of orthopedics at Lund University, Lund, Sweden, said.

The results regarding grip strength and range of motion were significantly better, but the DASH values were similar. We hoped to be able to prove an improvement using the subjective DASH outcome instrument, as well as in the distal radius fracture population as we have moved from the external fixator to internal fixation in a large proportion of our patients in the last decade, they said. “However, in a large population of all fractures, it remains the same over the decade.”

Treatment algorithm used

From 2002 to 2011, the researchers treated 3,712 patients who were 18 years old and older with distal radius fractures at Lund University and the patients were included in a prospective register.

For treatment, surgeons followed a previously published algorithm. Reducible distal radius fractures were put in a cast after reduction. Unstable non-reducible distal radius fractures had either external or internal fixation. The patients completed the DASH questionnaire at 3 months and 12 months postoperatively.

At the beginning of the study, surgeons used a bridging external fixator for dorsal fractures but gradually switched to the fragment-specific TriMed (Santa Clarita, Calif. USA) wrist fixation system for internal fixation. They began using the volar locking plate in 2006.

“We expected the results to have improved due to the introduction of the new volar plates,” Tägil told Orthopaedics Today Europe. “That does not appear to be the case, at least with the measuring method of using an outcome based on the patients’ experience: the DASH.”

DASH score improves

For the entire cohort, 2,006 patients (54%) completed the 3-month and 12-month DASH questionnaire. At 3 months, the overall median DASH score was 18 (0 to 98), which improved to 9 (0 to 95) at 12 months. There was only a small shift and no definitive trend during the study period.

The researchers divided the patients into three groups according to their residual symptoms based on DASH scores — major residual symptoms (>35), intermediary symptoms (11 to 35) and minor residual symptoms (0 to 10). About 10% of patients had substantial residual problems after 1 year.

Among the patients who were operated on, 544 completed the 12-month questionnaire. The median DASH score was 8 (0 to 93) after 1 year, and in the entire cohort there was no statistical significant difference in DASH scores seen 1 year after fracture or during the 10-year study period.

The investigators received the Bronze Free Paper Award at the EFORT Congress for this study. – by Colleen Owens

Reference:
Landgren M. Paper #13-4860. Presented at: EFORT Congress; June 5-8, 2013. Istanbul.

For more information:

Marcus Landgren, MD, and Magnus Tägil, MD, PhD, can be reached at the department of orthopaedics at Lund University, Lund, Sweden. Landgren’s email: marcus.langdren@med.lu.se. Tägil’s email: magnus.tagil@med.lu.se.

Disclosure: Landgren and Tägil have no relevant financial disclosures.